Complex Case Manager, Nurse​/Req

Brief Description
Hybrid:
Applicants must be a California resident as of their first day of employment.

This position works under the direct supervision of the Supervisor, Case Management and is responsible for the operational delivery of the plan’s case management and care coordination programs and processes.

The Complex Case Manager, Nurse will provide case management services for health plan members with highly complex medical and psychiatric conditions where advocacy and coordination are required to help the member reach the optimum functional level and autonomy. The Complex Case Manager Nurse will be working closely with a team comprised of the Complex Case Manager Nurse, a Medical Social Worker and a Health Navigator.

This collaborative team approach to case management will include key departments at the health plan, including Utilization Management and Pharmacy, which may provide clinical expertise and data on patient utilization patterns, often in real time, to the program. Externally, the team will work closely with community partners to make referrals for care and resources and to best manage members across the care spectrum and among multiple health care systems.

The goal of the Complex Case Management program is to improve members’ quality of life and assure cost-effective outcomes by utilizing all available and appropriate resources.

Principal responsibilities include:

• Perform the primary functions of assessment, planning, facilitation and advocacy through collaboration with the member and other health care resources involved in the member’s care.
• Work closely with licensed and unlicensed staff to co-manage the care of complex cases telephonically through regular contact with members, caretakers, healthcare professionals and others involved in the member’s care
• Carry a caseload of members individually and co-managed as a team
• The nurse will act a subject matter expert on the nursing process and perspective for the team
• The nurse will be responsible for triage and all aspects of the nursing process, including assessing, diagnosing, planning, implementing, and evaluating care.
• Develop multi-disciplinary care plans with the input of the member and PCP to address identified member problems using evidence-based goals and interventions
• Participate in the ongoing process of identifying the health plan’s members who are most at-risk of poor health outcomes and in need of care management services.
• Participate in weekly Multidisciplinary Care Team Meetings and be able to present complex medical cases before the department wide team
• The nurse will work with Health Homes members enrolled in internal Community-Based Care Management Entities (CB-CME) per Department of Health Care Services guidelines.
• Work collaboratively with health plan’s providers, particularly member’s primary care providers and specialists, in order to provide highly coordinated and often specialized care
• Assess member medical and social determinants of health
• Communicate with providers, members, and community resources as necessary, to support the planning, implementation and evaluation of care management programs.
• Employ a patient advocacy approach with a seamless integration of services is required and must be balanced within the member's benefit structure.
• Complete other duties and special projects as assigned.

• Communicate and coordinate required services for members with PCP’s and specialists.
• Manage, document, and maintain casework in accordance with NCQA accreditation guidelines and state regulators.
• Build and maintain effective relationship with designated members and those members’ families or caregivers.
• Maintain case management records.
• Develop appropriate member care plans and appropriate member assessments.
• Serve as a clinical resource to staff, as needed.
• Perform writing, administration, analysis, and report preparation.
• Research and develop working relationships with appropriate community resources to service members.
• Provide direction to ancillary team/pod staff members who will provide additional coordination activities for health plan members being case managed.
• Comply with…